Prostate abscess presenting as priapism.

Abscesses of the prostate are infrequently encountered now as a result of effective antibiotics. The clinical diagnosis remains difficult. Herein we report an unusual case of a prostate abscess presenting as priapism. The diagnosis and management of the case is discussed, and the literature is reviewed.

Eliciting preferences for drug treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia.

PURPOSE: There are 2 main medical preparations available for lower urinary tract symptoms resulting from benign prostatic hyperplasia (BPH). Choosing between an alpha-blocker and a 5alpha-reductase inhibitor requires trade-offs between their attributes or characteristics. We investigated the relative importance of and trade-offs between the attributes of the 5alpha-reductase inhibitor dutasteride and alpha-blockers in community dwelling men using a validated technique. MATERIALS AND METHODS: A discrete choice experiment was administered to 211 men older than 40 years who were randomly selected from the general United Kingdom population. Attributes investigated in the discrete choice experiment were time to symptom improvement, sexual and nonsexual side effects, the risks of acute urinary retention (AUR) and surgery, cost and prostate size decrease. Using regression analysis the relative importance of these attributes, the trade-offs that men are willing to make between these attributes and the willingness to pay for each attribute were estimated. RESULTS: All attributes were important to respondents. The most important attribute was side effects. The least preferred side effects was impotence, followed by decreased libido and dizziness. Respondents were willing to wait 13, 2 and 8 months longer for symptom improvement in exchange for decreased prostate size, and the risks of AUR and surgery, respectively. Men reporting moderate symptoms were less concerned about sexual side effects, time to symptom improvement and the risk of AUR compared with men reporting mild symptoms. CONCLUSIONS: Given the attribute levels of BPH medical treatment, overall community dwelling men preferred the 5alpha-reductase inhibitor over alpha-blockers. In the interests of shared decision making it is important to consider the importance of eliciting the preferences of patients with BPH.

Acute idiopathic scrotal oedema in an adult: a case report.

In the evaluation of a patient of any age presenting with an acute scrotal swelling, a surgical emergency should be carefully excluded. However, acute idiopathic scrotal oedema must be considered to avoid unnecessary surgical exploration.

A rare complication of a prostatic stent.

We describe a case in which an elderly man with deteriorating lower urinary tract symptoms had problems with an indwelling prostatic stent. We discuss the merits of prostatic stents and recommend indications for their use.

Thermo-expandable intraprostatic stents in bladder outlet obstruction: an 8-year study.

OBJECTIVE: To assess the use of a thermo-expandable intraprostatic stent (Memokath(R), Engineers and Doctors A/S, Copenhagen, Denmark) for bladder outlet obstruction in men unable to undergo transurethral resection of the prostate (TURP), assessing symptoms, complications and duration of stent life. PATIENTS AND METHODS: The Memokath stent is a coil of a nickel-titanium alloy which has 'shape memory', the lower end expanding when heated to 55 degrees C. Risks associated with inserting the stent with a flexible cystoscope under local anaesthesia are minimal. Men were selected who were either permanently or temporarily unfit for TURP. Indications included severe respiratory and cardiovascular disease. Exclusion criteria included bladder carcinoma, calculi or detrusor failure; in all, 211 men were fitted with 217 intraprostatic stents over 8 years. RESULTS: There were 1511 TURPs during the study period; the mean age of men receiving a stent was 80.2 years, compared with 70.2 years for those undergoing TURP. The International Prostate Symptom Score decreased from a mean of 20.3 to 8.2 (P < 0.001) in the first 3 months after stent placement; there was virtually no change over 7 years. During the follow-up, 38% of men died with their stents in situ, 34% remain alive, 23% have had their stents removed for failure and 4% were removed as they were no longer required. There was a 13% migration rate and 16% repositioning rate. There were few side-effects (pain 3%, haematuria 3%, incontinence 6% and infection 6%). These frail men were more likely to die than have their stent fail. CONCLUSION: The Memokath intraprostatic stent is a valuable addition to the armamentarium of the urologist treating elderly or frail men with advanced bladder outlet obstruction and complements existing technologies.

The nurse cystoscopist: a feasible option?

OBJECTIVES: To compare the accuracy achieved by a trained urology nurse practitioner (UNP) and consultant urologist in detecting bladder tumours during flexible cystoscopy. PATIENTS AND METHODS: Eighty-three patients underwent flexible cystoscopy by both the UNP and consultant urologist, each unaware of the other's findings. Before comparing the findings, each declared whether there was tumour or any suspicious lesion requiring biopsy. RESULTS: Of 83 patients examined by flexible cystoscopy, 26 were found to have a tumour or a suspicious lesion. One tumour was missed by the UNP and one by the urologist; each tumour was minute. Analysis using the chance-corrected proportional agreement (Kappa) was 0.94, indicating very close agreement. CONCLUSION: A UNP can be trained to perform cystoscopy and detect suspicious lesions as accurately as can a consultant urologist. Legal and training issues in implementation are important.

The care pathway: a tool to enhance clinical governance.

A care pathway defines in detail the individual components of treatment for a group of patients. A well-written pathway can lead to consistent care of the highest quality. There are both educational and audit advantages to the approach. The authors detail the means by which groups are selected and the care pathways written. An example of the benefits that can accrue comes from their experience at Ashford Hospital of running a pathway for patients having prostate surgery. The pathways are appreciated by patients, nurses, doctors and managers. Care is improved, costs contained and clinical governance enhanced.

A clinical view of pathways of care in disease management.

Pathways of care define in detail the individual components of treatment for a group of patients. A well written pathway can give rise to consistent care or the highest quality. There are both educational and audit advantages to the approach. Details the means by which groups are selected and the care pathways written. Gives an example of the benefits that can accrue, based on the authors' experience at Ashford Hospital, UK of running a pathway for patients having prostate surgery. The pathways are appreciated by patients, nurses, doctors and managers. Care is improved and costs contained.

The management of superficial bladder cancer: an interactive seminar.

OBJECTIVES: To determine the current management of superficial bladder cancer in the United Kingdom. METHODS: An interactive seminar with a series of questions about management and hypothetical clinical scenarios was conducted at the 1995 conference of the British Association of Urological Surgeons. The responses of the audience were recorded electronically and analysed. RESULTS: The results showed that there is a wide variation in practice and some confusion over the place of intravesical treatment using cytotoxic drugs and bacille Calmette-Guérin. CONCLUSIONS: The management of superficial bladder cancer could be improved by a more widespread use of intravesical therapy, along with the introduction of local protocols and national guidelines.

Clinical information system that enhances the use of resources in endoscopic prostatic procedures.

In this study we evaluated, by means of an automated management system, the identification of subgroups of patients within certain operative categories whose predictable length of stay was compatible with treatment on a 5-day ward. This was achieved by using a computer directed analysis of urological workload on prospectively collected clinical data. Graphical presentation of the results was achieved by a technique known as the patient-bed dissociation curve. Patients with bladder outflow obstruction treated by transurethral prostatic resection (701) and bladder neck incision (113) were selected from a total of 7,162 hospital admissions. The main outcome measures were length of stay and complication rates for the 2 procedures. The results demonstrated that a group of patients about to undergo transurethral resection could be selected by age and source which would indicate an 18% greater probability of discharge within 5 days. These patients were easily identifiable in advance and would be suitable for treatment on a 5-day ward. It was concluded that computer-held clinical data were easily accessible to the surgeon. The process of detailed analysis need not take time. With properly directed studies the information retrieved could be used to effect change. The patient-bed dissociation curve may prove a valuable tool in examining and comparing discharge patterns in any groups of patients.

Seminoma or sarcoid?

A 33-year-old man subsequently diagnosed as having sarcoidosis presented with the clinical features of a testicular tumour with metastatic spread to para-aortic lymph nodes. Histological examination of the testis and para-aortic lymph node biopsy showed florid granulomatous change and a Kveim test was positive. This is a previously unreported presentation of sarcoidosis and emphasizes that histological confirmation of malignancy is essential prior to institution of cytotoxic therapy.

Comparative audit: a new method of delivering audit.

A new method of audit delivery is described, based on the first large scale comparative audit meeting held at The Royal College of Surgeons of England. The concept of comparative audit is introduced and the methods of undertaking such an exercise are described. This comparative audit processed the clinical activity of 45 general surgeons during 1989 amounting to 49,005 patient admissions. As an illustration of this technique the comparative analysis of 3,710 inguinal hernia procedures accounting for 12,600 total stay days is used in order to illustrate data manipulation, ranking and presentation in chart form. Conclusions are drawn and suggestions as to the future role of the technique are outlined.

Management importance of common treatments: contribution of top 20 procedures to surgical workload and cost.

OBJECTIVE: To assess the contribution of the most frequently performed procedures to surgical workload and to evaluate the financial implications. DESIGN: Analysis of data held on the department's computerised clinical information system. SETTING: Department of surgery in a district general hospital. PATIENTS: 4845 patients were treated by surgeons in three consultant firms over an 18 month period and 5346 patients by surgeons in a single firm over a five year period. MAIN OUTCOME MEASURES: Percentage and cumulative percentage contribution to workload in order of frequency by procedure. Costs of the commonest and costliest treatments. RESULTS: Half of the workload of the department was encompassed by eight procedures. Twenty procedures accounted for 70% of the work. For a single firm 20 procedures represented over 80% of all the surgical work. Transurethral prostatectomy was the treatment that consumed most resources (pounds 240,900 for 198 patients in 18 months). The costliest patients were those who had undergone complicated large bowel surgery, vascular reconstructions, or amputation. CONCLUSIONS: Clinicians and managers need to appreciate the importance of the most common surgical procedures. It is vital that performance and costing of these procedures are optimum as they contribute disproportionately to overall results and finance.